PERVASIVE DEVELOPMENTAL DISORDER PROFESSIONAL PROVIDERS 7/1/2017

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1 PERVASIVE DEVELOPMENTAL DISORDER PROFESSIONAL PROVIDERS 7/1/2017 Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association

2 Practice Information Credentialing Eligibility and Benefits Magellan Healthcare, Inc. Authorization Claim Submission Claim Reimbursement Quick Guide 2

3 CAPITAL BLUE CROSS Capital BlueCross contracts with providers of Applied Behavioral Analysis (ABA) services, including psychiatrists, psychologists, social workers, licensed behavioral specialists and other master s prepared therapists licensed in the state of Pennsylvania. For Traditional, Comprehensive, PPO, and POS members, services may be provided by a professional behavioral health provider that is contracted with Capital BlueCross. On behalf of Capital BlueCross, Applied Behavioral Analysis (ABA) services assists in the administration of behavioral health benefits. ABA is an independent company. 3

4 PRACTICE INFORMATION Report any changes to your practice information as soon as possible. As a participating provider, you are able to complete many of these change requests online through the NaviNet portal. To locate the forms, select Provider Library from the drop down provided, click on Forms, Guides & Directories, and select Professional Provider Information Exchange Forms. Contact the Capital BlueCross Customer Service Call Center at with any practice demographic changes that cannot be completed online. NaviNet is an independent company providing this provider portal service on behalf of Capital BlueCross. 4

5 CREDENTIALING Only credentialed providers may provide covered services to Traditional, Comprehensive, PPO, and POS members. Services should not be rendered until you have received notification that the credentialing process has successfully been completed. Providers must be recredentialed at least every three years. Capital BlueCross delegates the credentialing process to Magellan Healthcare, Inc. Behavioral health providers must be credentialed by Magellan prior to participation in Capital BlueCross networks. On behalf of Capital BlueCross, Magellan Healthcare, Inc. assists in the administration of behavioral health benefits. Magellan Healthcare is an independent company. 5

6 CREDENTIALING To add new practitioners to your group, access the Behavioral Health Provider Data Form and the Magellan Referral Supplement Form located in the Provider Library under Professional Provider Information Exchange Forms on the Capital BlueCross health plan home page via the NaviNet portal. Capital BlueCross staff will forward your practitioners information to Magellan to complete the credentialing process. Magellan may reach out to the practitioner for additional information during the credentialing process. It is very important that the practitioner responds to these requests. When all required information is received by Magellan, the credentialing process will begin. The credentialing process can take up to 180 days as dictated by National Committee for Quality Assurance (NCQA), the national standard for health care credentialing. Questions regarding the status of credentialing can be made to Magellan at

7 CREDENTIALING Upon successful credentialing, letters are mailed to your practice notifying you that the new practitioner has been recommended for participation in the Capital BlueCross family of companies professional provider network. Please note that the practitioner s status as a participating provider will not be established until you receive a second letter containing the practitioner s provider identification number and an effective date for the commencement of their participation. The practitioner should not provide service to a member until receipt of the second letter containing the practitioners effective date. 7

8 ELIGIBILIT Y AND BENEFITS Before providing services to Traditional, Comprehensive, PPO, and POS members, eligibility and benefits should be verified. Go to the Capital BlueCross home page on the NaviNet portal and enter your sign-on. The NaviNet portal should also be used for members who are covered by another Blue Plan. This is generally referred to as BlueCard. Additional information regarding BlueCard can be found in the Provider Manual or in the Provider Library. The mandate Pennsylvania Act 62 of 2008 does not apply to all products and plans. Please be sure to verify eligibility and benefits for all patients seeking these services. Some employer groups have made alternative arrangements for the provision of behavioral health services for their employees and may have contracted with a behavioral health vendor other than Magellan. In those instances, the member s ID card will either contain no behavioral health information, or refer the provider to a vendor other than Magellan. In the event that there is no information about behavioral health benefits on the member s ID card, the member is responsible for obtaining behavioral health services in accordance with the benefits provided by their employer. BlueCard is a trademark of the BlueCross BlueShield Association. 8

9 MAGELLAN HEALTHCARE, INC. Magellan performs credentialing and utilization management, including preauthorization, concurrent review, and respective review. Capital BlueCross contracts with Magellan for its behavioral health network and management of behavioral health services for commercial HMO members. Behavioral health practitioners who wish to contract with Magellan for commercial HMO members, should contact Magellan at 9

10 AUTHORIZATION OF SERVICES There are no referral requirements for ABA services. However, preauthorization may be required. A comprehensive list of services that require preauthorization is available in the Provider Library under Preauthorization Single Source Preauthorization List. Chapter 11 of the Capital BlueCross Provider Manual, located in the Provider Library, contains additional information regarding preauthorization requirements. 10

11 CLAIM SUBMISSION In order to be eligible for reimbursement consideration, providers of ABA services are required to report ABA services using the most appropriate Level II Healthcare Common Procedure Coding System (HCPCS) procedure codes AND Level II HCPCS modifiers from the list below. Providers must also report total units (time based) for each service reported. H Applied Behavior Analysis (ABA) Initial Assessment & Plan Development or behavior specialist consultant, per 15 minutes* *Note: Reimbursement for the services reflected in this code description (H0032) will not exceed the equivalent of 16 units [4 hours] of service. H Applied Behavior Analysis (ABA) Follow-up & Reassessment or mobile therapy, per 15 minutes H Applied Behavior Analysis (ABA) Follow-up & Reassessment or therapeutic staff support, per 15 minutes H Supervision of Applied Behavior Analysis follow-up or therapeutic staff support, per 15 minutes 11

12 CLAIM SUBMISSION Providers are required to report one of the following Level II HCPCS Modifiers with the appropriate Level II Procedure Code (listed above) based on the education level of the provider performing the service. If a procedure code for ABA is submitted without one of these modifiers, the service will be denied as invalid modifier/procedure combination and the provider will be required to resubmit the charge with the appropriate modifier. HP - Doctoral Level Board certified behavior analyst or behavior specialist consultant HO Master s Degree Level Board certified behavior analyst, behavior specialist consultant, or mobile therapist HN - Bachelor s Degree Level Board certified assistant behavior analyst HM - Less than Bachelor s Degree level non-certified support staff or therapeutic staff support 12

13 CLAIM SUBMISSION Traditional, Comprehensive, PPO, POS, and BlueCard claims should be submitted to Capital BlueCross electronically via the NaviNet portal (navinet.navimedix.com) or by paper (CMS 1500 claim form) to: Capital BlueCross PO Box Eagan, MN Commercial HMO Claims should be submitted to: Magellan Healthcare, Inc. PO Box 1238 Maryland Heights, MO

14 CLAIM REIMBURSEMENT Standard fees for Traditional, Comprehensive, PPO, and POS members can be found on NaviNet in the Network Resource Center under Fee Schedule Inquiry. Capital BlueCross Professional Provider Network Reimbursement Policies can be found in the Provider Library on NaviNet. NR titled Reimbursement for the Diagnosis and Treatment of Autism Spectrum Disorders is a valuable resource. Note: that Capital BlueCross Professional Provider Network Reimbursement Policies do not have any impact on member benefits or medical necessity. Contact Magellan directly for fees related to commercial HMO members. 14

15 QUICK GUIDE Capital BlueCross C redentialing Status ( D e l e g a t e d t o M a g e l l a n ) Authorization ( D e l e g a t e d t o M a g e l l a n ) C laims Filing - Electronically via the NaviNet por tal (navinet.navimedix.com) or by paper (CMS 1500 claim form) to: Capital BlueCross PO Box Eagan, MN C laim Inquiries, Eligibility Verification, Benefit Q uestions - Access NaviNet or call the Capital BlueCross Customer Ser vice Call Center at BlueCard Members Eligibility and Benefits C laim Inquiries Magellan Healthcare, Inc. Contracting and Credentialing Authorization Claims Filing Submit commercial HMO Claims through: Magellan Healthcare, Inc. PO Box 1238 Mar yland Heights, MO Claim inquiries, Eligibility Verification, Benefit Questions - Call the Magellan Provider Ser vice Line at